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Are you a member of a HMO but not getting the coverage you need for proper diabetes care? After finding a primary care physician who is sympathetic to your needs, you may need to contact your HMO and appeal for coverage for the services and equipment you need for good preventative care.
The following letter can be used when seeking coverage for an insulin pump, a blood glucose meter, regular hemoglobin A1c tests, access to a podiatrist, access to an ophthalmologist, payment of test strips for my blood glucose meter, or one of the many other essentials to good diabetes care. See page 20 for a list of quotes from respected professional medical journals regarding the importance and economic benefit of various diabetes care practices and products that can be used to support your request.
This letter is adapted from letter templates developed by Kriss Halpern, a Fort Lauderdale, Fla., attorney who works with patients having disputes with HMOs.
As with all correspondence with your HMO regarding coverage, keep copies of this letter and all responses. In addition, Halpern advises sending letters like this one certified mail, return receipt requested.
(Use your home or office address as a formal letterhead.)
123 Advocate Street
San Francisco, CA 94117
Fax (415) 387-3604
June 1, 1998
Attention: (Insert name of manager of member services, program administrator or similar title)
Name of HMO
Address of HMO
(Include direct telephone number of person to whom you are sending this letter for your records.)
Sent by Certified Mail - Return Receipt requested
Re: (Patient's name), (HMO's name), (Acct. No.)
Dear (Name of administrator):
I am writing with regard to the care and treatment (the HMO) is providing for my diabetes management.
As a type 1 (or type 2) diabetic on (your HMOs) plan through (insert your employer, university or whatever specific plan you are enrolled in), I am requesting that you provide me with (the service or product you are requesting). These/this diabetes management tool/care/service is crucial to the proper management of my diabetes.
The (requested service or product) could enable me to better control my blood glucose levels.
In addition, I will need annual eye exams and nerve and kidney tests. I will need blood tests taken every three months to determine my hemoglobin A1c (HbA1c) levels. This test measures blood glucose over a longer period of time than the blood glucose meter tests and is a better judge of long-term management. The results of this test are crucial in determining the degree of success of my blood glucose control program.
There are a variety of other services I will need to manage my treatment. Attached please find a copy of the Diabetes Coalition of California's Health Record (see page 23) which lists the minimal level of care necessary for a person with diabetes. Without the provision of these standard testing procedures, clinical studies, including the National Institutes of Health's 1993 Diabetes Control and Complications Trial (DCCT), have shown that the likelihood of vastly more extensive and expensive complications is dramatically increased.
My hope is that I will convince your company to provide better diabetes care for me, and that other diabetics can enjoy the benefits of a smart and progressive management program based on tight control of the disease and prevention of its many complications.
If you have any questions, please call.
Diabetes Health is the essential resource for people living with diabetes- both newly diagnosed and experienced as well as the professionals who care for them. We provide balanced expert news and information on living healthfully with diabetes. Each issue includes cutting-edge editorial coverage of new products, research, treatment options, and meaningful lifestyle issues.